When open surgery fails: endovascular treatment of a surgically inaccessible high cervical internal carotid artery aneurysm – a case report

Abstract

Extracranial internal carotid artery (ICA) aneurysms are rare vascular lesions associated with a risk of thromboembolism, rupture, and cranial nerve compression. Open surgical reconstruction has traditionally been considered the standard treatment; however, lesions located high in the cervical segment may pose significant technical challenges due to limited exposure and difficulty in obtaining distal control. This report describes the case of a 36-year-old man presenting with several weeks of left-sided neck pain and headache. Computed tomography angiography demonstrated a saccular aneurysm of the proximal left ICA measuring approximately 31×17×18 mm. Open surgical repair was attempted but intraoperative findings revealed a high cervical aneurysm with a fragile arterial wall and inability to safely obtain distal control, leading to abandonment of reconstruction. Definitive treatment was subsequently achieved using a staged endovascular approach with deployment of a covered stent graft. Completion angiography confirmed complete exclusion of the aneurysm with preserved antegrade flow and no evidence of endoleak. The postoperative course was uneventful and the patient remained neurologically intact. This case highlights the importance of intraoperative decision-making and supports endovascular reconstruction as an effective alternative in anatomically challenging extracranial carotid aneurysms.